Reimbursement for Tests with the OCULUS Pentacam (OCULUS)
FREQUENTLY ASKED QUESTIONS:
REIMBURSEMENT FOR TESTS WITH THE OCULUS PENTACAM
© Corcoran Consulting Group
For best results, please view in Mozilla Firefox.
Q What tests can be performed with the OCULUS Pentacam® and Pentacam® AXL?
A The Pentacam is a multipurpose diagnostic instrument for evaluating the anterior segment; there are several models with different features. Tests performed with Pentacam, either alone or as part of another service, include:
- Optical tomography of the anterior segment (SCODI-A, CPT 92132)
- External ocular photography (CPT 92285)
- Corneal topography (CPT 92025)
- Optical corneal pachymetry (Unlisted test)
- Zernike and wavefront analysis (CPT 92015)
- Planning phakic IOL (Part of refractive surgery)
- Ophthalmic biometry, white-to-white and anterior chamber depth (Part of biometry)
- Contact lens fitting (Part of CL service)
- Lens densitometry (Part of an eye exam)
Q Does Medicare cover scanning computerized ophthalmic diagnostic testing of the anterior segment (SCODI-A)?
A Yes, to a limited degree. In 2011, CPT 92132 replaced 0187T to report SCODI-A. Few Medicare Administrative Contractors (MACs) have published policies and they only include indications for narrow anterior chamber angles and iris abnormalities.
Q Does Medicare cover external ocular photography and corneal topography?
A Yes, but since no national Medicare policy exists for either test, reimbursement is at the discretion of each MAC.
Q Does Medicare cover corneal pachymetry?
A Yes; most MACs have published policies to cover this test. Coverage is based on two distinctly different indications: (1) corneal disease, and (2) ocular hypertension and glaucoma. CPT code 76514, by virtue of its designation as a radiological procedure, only describes pachymetry when using ultrasound. When the Pentacam is used for optical corneal pachymetry, it is reported with CPT code 92499 (unlisted ophthalmological service or procedure).
Q Does Medicare cover Zernike and wavefront analysis?
A No. This test is refractive in nature, although it moves beyond the familiar sphere, cylinder and axis that is commonly found in refraction (CPT 92015), and is additive with the basic service. In CPT, modifier -22 is used with a code to report an unusual service that is greater than that usually required for the listed procedure. Within the Medicare program, refraction is not a covered service.
Q What are Medicare’s reimbursement rates?
A In 2016, the national Medicare Physician Fee Schedule rates are as follows.
These values are modified by local wage indices so actual payment rates vary.
Q What documentation is required in the medical record?
A Where a physician’s “interpretation and report” are required, a brief notation such as “abnormal” does not suffice. In addition to the images, the medical record should include:
- order for the test with medical rationale
- date of the test
- the reliability of the test (e.g., cloudy due to corneal scar)
- test findings (e.g., narrow angles)
- comparison with prior tests (if applicable)
- a diagnosis (if possible)
- the impact on treatment and prognosis
- physician’s signature
Q Is it possible to bill for more than one test on the same day?
A Yes. Multiple tests may occur and be billed on the same day as long as there is sufficient justification for each service and the services are not duplicative, bundled, or mutually exclusive. For instance, assessing different parts of the eye using different tests is one justification, as occurs when corneal topography is performed concurrent with SCODI-A. Additionally, patients may have several co-morbidities that warrant investigation using different tests.
Obvious duplication occurs when the same digital image of the eye is billed twice. For example, we do not advocate billing external photography and SCODI-A concurrently because the individual digital slices are collectively the tomogram.
92132, 92025 and 92285 are all subject to Medicare’s Multiple Procedure Payment Reduction (MPPR). This reduces the allowable for the technical component of the lesser-valued test when more than one test is performed on the same day.
Q How frequently may I perform diagnostic testing with the Pentacam?
A Some reasons for repeated testing include:
- During the eye exam that precedes the order for another test, the physician has formed a suspicion that the patient’s condition has changed for the worse due to:
- objective evidence of vision loss
- new symptoms or complaints
- a recent surgical intervention
- exam findings of disease progression
- Earlier tests are no longer reliable.
- The AAO’s Preferred Practice Patterns may suggest repeat testing at specific intervals which vary based on the disease and its progression.
Q If Medicare does not cover the test(s) may I charge the patient?
A Explain to the patient why the test is necessary, and that Medicare or other third party payer will likely deny the claim. Ask the patient to assume financial responsibility for the charge. A financial waiver can take several forms, depending on insurance.
- An Advance Beneficiary Notice of Noncoverage (ABN) is required for services where Part B Medicare coverage is ambiguous or doubtful, and may be useful where a service is never covered. You may collect your fee from the patient at the time of service or wait for a Medicare denial. If both the patient and Medicare pay, promptly refund the patient or show why Medicare paid in error.
- For Part C Medicare (Medicare Advantage), determination of benefits is required to identify beneficiary financial responsibility prior to performing noncovered services; MA Plans may have their own waiver forms.
- For commercial insurance beneficiaries, a Notice of Exclusion from Health Plan Benefits (NEHB) is an alternative to an ABN.
Provided Courtesy of OCULUS, Inc. (888) 284-8004
Last updated April 26, 2016
The reader is strongly encouraged to review federal and state laws, regulations, code sets (including ICD-9 and ICD-10), and official instructions promulgated by Medicare and other payers. This document is not an official source nor is it a complete guide on reimbursement. The reader is reminded that this information, including references and hyperlinks, changes over time, and may be incorrect at any time following publication.
© 2016 Corcoran Consulting Group. All rights reserved. No part of this publication may be reproduced or distributed in any form or by any means, or stored in a retrieval system, without the written permission of the publisher.
Corcoran Consulting Group (800) 399-6565 www.corcoranccg.com